Observational Surveys
There are a total of 5 progress tools to be used for the practice surveys: 1) Observational Surveys; 2) Session1 Participatory Survey; 3) Session 2 Participatory Survey; 4) Session 3 Participatory Survey; and 5) Team Coordinator. The Team Coordinator’s progress tool is to be completed prior to the Field Manager’s request for the new surveyor’s compliance surveys. Each progress tool is completed by the Peer Coach and the New Surveyor followed by a face to face meeting between the Field Manager, New Surveyor and Peer Coach to discuss progress and/or concerns.
STAFF’S NAME / DATE OF HIRE / COACH’S NAME / DISTRICT / UNIT
ON-SITE VISIT DATE(S) (MM/DD/YYYY) / NURSING HOME NAME
Expectation:
It is expected that new staff members perform at least one “observation only” survey prior to attending RCS Orientation. It is expected that more than one observational survey may be needed to cover all aspect and steps of a survey.
Key Elements:
· Due to the added responsibilities, the Peer Coach (PC) should be assigned minimal extra survey tasks and protocols. The Staff Member will observe the Peer Coach conduct a full Stage 1 assignment and a full Stage 2 assignment. The PC should not be assigned as the team leader.
· Staff Member (SM) should not be assigned any resident reviews. Staff member should be encouraged to practice recording observations on their computer which will not be synched as part of the team information.
Place appropriate observed code next to each critical element. When appropriate, the Peer Coach should describe in the “notes sections” the event that led to the coding within the section and identify and add specific opportunities for growth in needed areas.
Progress Level Key:
PROGRESS LEVEL / CODE / DESCRIPTION
Observation Only / O / Observed survey; did not perform any tasks or elements.
Demonstrated with Coaching / DC / Required the availability of the PC to provide directed assistance and identify areas for improvement.
Demonstrated with Minimal Coaching / D / Required the availability of the PC to answer questions and give minimal direction.
Performed Independently / I / Performed the survey tasks and elements independently.
No applicable / NA / Element has previously been performed at the independent level or was not attempted.
Task 1: Off-site Preparation
The purpose of the offsite survey preparation is to gather preliminary information about the facility prior to survey, and prepare the team computers for the survey.
Staff Member Preparation:· Prior to survey and off-site prep view the CMS Quality Indicator Survey (QIS) Process archive web-based training. http://surveyortraining.cms.hhs.gov/index.aspx)
· Download the following forms from: : http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/QIS-Resources-Guides.html
The QIS Checklist
Off-site Preparation Worksheet (CMS 20044 dd. 11/2010)
QIS Brochure
All Stage 1 Form for Admission and Census Sample
· Review the team’s Offsite survey preparation worksheet.
· Review the Checklist Steps 1 – 8.
Objectives / Critical Elements:
O DC D I NA
Actively observed team review of off-site materials.
Listened attentively and actively observed the team during the off-site preparation.
Asked appropriate questions of Peer Coach.
NOTES
Task 2: On-site Preparation
The purpose of the offsite preparation is to continue data gathering, reconciling the residents in the resident pool to the residents in the facility, and making Stage 1 assignments.
Staff Member Preparation:· Print and review the team copy of the entrance Conference Worksheet.
· Review QIS Checklist Steps 9 – 19.
A. Attend the Entrance Conference
Staff Member Preparation:
· Review the team copy of the entrance conference worksheet.
Objectives / Critical Elements:
O DC D I NA
Attended and actively listened as the team coordinator conducted the entrance conference.
Reviewed the meeting with the team coordinator and asked clarifying questions.
NOTES
B. Initial Tour
Staff Member Preparation:
· Review the QIS Initial Tour in ASE-Q.
Objectives / Critical Elements:
O DC D I NA
Actively observed the peer coach during the tour.
Focused and recorded observations of clean, safe and homelike environment and appropriate infection control practices. Specifically noted and recorded issues and concerns of residents.
Practiced documenting observations in the Initial Tour and Surveyor Notes fields in ASE-Q with correct time, date, and heading.
Actively observed coach introducing his/her self to residents and staff. Observed coach in their interactions with staff and residents. Observed and noted resident activities. Met and greeted staff and observed PC record licensed staff names for reconciliation to the staffing schedule.
Listened and identified types of questions asked by surveyor of residents, family and staff.
NOTES
C. Reconciliation and Initial Team Meeting
Staff Member Preparation:
· Review the instructions for reconciliation in ASE-Q with staff doing reconciliation.
· Review forms and information provided by Nursing Home to familiarize you with the types / sources of information.
· Review the Initial Team Meeting agenda at Step 18 on the QIS Checklist.
Objectives / Critical Elements:
O DC D I NA
Identified the facility forms needed for reconciliation.
Actively observed the reconciliation process. Reviewed materials that were used.
Observed the team sharing information gathered during the tour and provided by the Nursing Home during the entrance conference.
Identified agenda items of the first team meeting Step 18 in the QIS Checklist.
Asked appropriate questions of coach at the appropriate times.
NOTES
Task 3: Stage 1 Survey
Stage 1: Resident Review for Census and Admission Sample Residents
The purpose of Stage 1 survey is to gather data related to the quality of life and quality of care of Stage 1 sampled residents using prescribed protocols and structured sets of questions.
Staff Member Preparation:· Review the QIS Checklist Steps 20 and 21.
· Review Census Sample data fields in ASE-Q on the PC’s computer: Resident Interview, Resident Observation, Staff Interview, Record Review, and Family Interview.
· Attended and reviewed the Stage 1 Team Meetings. Review Checklist Step 22.
Objectives / Critical Elements:
O DC D I NA
Actively observed the Peer Coach making and recording observations of Stage 1 census sample residents.
Listened intently during resident and staff interviews.
Asked questions and requested information at the appropriate time.
Reviewed the Peer Coach’s Resident Relevant findings and clarified the probes.
Staff member practiced recording the details of the Peer Coach’s sample residents.
With coach, reviewed a Stage 1 admission record to gain familiarity with nursing home resident records, location of information, etc.
NOTES
Task 4: Facility Tasks (Mandatory and Triggered)
Task 5: Transition Stage 1 to Stage 2
The Primary objective of this meeting is to discuss the concerns associated with each triggered Care Area and the extent of the QCLI calculations in relation to the thresholds. Each surveyor views the QCLI’s on their screen and discusses concerns in relation to their Stage 1 resident assignment.
Staff Member Preparation:
· Review QIS Checklist Steps 27 - 34.
· Review tasks associated with synching each team member’s data with the TC.
· Review the QCLI’s and team discussion during the transition meeting on PC’s computer.
· Review Stage 2 Assignments, Stage 2 Care Areas and Stage 2 Sample.
Objectives / Critical Elements:
O DC D I NA
Observed and followed the team discussion of the QCLI’s, the care areas that triggered with “met criteria” and those did not.
Reviewed the thresholds and what residents met the criteria. Asked questions and requested information at the appropriate time to facilitate understanding.
Listened and observed the team discussion of care areas that needed to be supplemented based on the SQC areas of Quality of Life, Quality of Care and Resident Behavior Facility Practice.
NOTES
Task 6: Stage 2
The purpose of this task is to conduct an in-depth directed investigation of the triggered and initiated Care Areas using investigative protocols. It also includes completing investigations of the mandatory facility tasks and the triggered facility tasks.
Staff Member Preparation:
· Review QIS Checklist Steps 37 – 41.
· Review each facility task Worksheet/CE pathway.
· Review each Care Area CE pathway in the peer coach’s Stage 2 sample.
· Review investigations of a care area with a CE pathway and one without a CE pathway.
· Followed agenda for Stage 2 team meetings at QIS Checklist Step 39.
· Prior to Analysis and Decision Making Review QIS Checklist Steps 40 – 42.
Objectives / Critical Elements:
O DC D I NA
Looked, actively listened and learned how to conduct in-depth investigations.
Observed how peer coach organized data gathering: observation, interviews and record reviews for each assigned care area and resident in his/her Stage 2 assignment.
Observed how the coach performed focused resident reviews.
Asked pertinent questions at the appropriate time.
NOTES
Task 7: Analysis and Decision Making
The purpose of the Stage 2 Analysis and Decision Making is to discuss the Potential Citations, and accompanying documentation resulting from facility tasks and Stage 2 investigations to determine whether noncompliance exists; and to make team decisions about the severity and scope for the citations.
Staff Member Preparation:
· Review QIS Checklist Steps 43 – 48.
Objectives / Critical Elements:
O DC D I NA
Observed team discussion and determination of issues / concerns regarding Nursing Home practices.
Observed the team process for determination of non-compliance and scope and severity.
NOTES
Exit Conference
The QIS exit conference informs the facility of the survey team’s observations and preliminary findings.
Staff Member Preparation:
· Review QIS Checklist Step 48.
· Review the State OPP for Communication with the facility.
http://adsaweb.dshs.wa.gov/docufind/MB/RCSMB2012/R12-029%20-%20NH%20Communication%20OPP.doc
· Review the Attachments in the link to the above Management Bulletin (MB).
Objectives / Critical Elements:
O DC D I NA
Observed how failed nursing home practice determinations from Task 8 are summarized and presented to the public audience.
Observed how team coordinator/team member(s) obtained further information about failed practice from the facility.
Actively discussed the findings of the team with the coach.
NOTES
Post Survey Activities: Report Writing
Staff Member Preparation:
· Review the Principles of Documentation.
· Participate in team meetings for editing.
Objectives / Critical Elements:
O DC D I NA
Reviewed survey report during various stages of preparation.
Reviewed regulation and guidelines for each “tag” cited.
NOTES
Staff Member brought State Operations Manual Transmittals (SOM) and Appendixes.
Used appropriate forms and tools Self Evaluation of professional Manner.
Check all that apply and add other descriptors in the “other” box.
Projects and promotes a positive image / attitude / working relationship
Identifies areas of improvement and responds favorably to suggested actions for improvement
Stern
Condescending
Communicates effectively
Challenging
Open to new ideas
Tactful
Punctual
Focuses on relevant and essential issues
Defensive
Applies new concepts and techniques effectively
Unsure / hesitant / indecisive
Forceful / argumentative
Assertive
Strident
Other:
STUDENT TRAINING STRENGTHS
STUDENT TRAINING WEAKNESSES
Actions recommended to address identified weaknesses:
Does not meet or demonstrate standards
Is recommended to continue field training with focus on weaknesses
Is recommended to repeat this training
Is recommended not to proceed in the training program
FIELD MANAGER, PEER COACH, STAFF MEMBER MEETING / REVIEW NOTES
GOALS FOR IMPROVEMENT
PEER COACH’S SIGNATURE DATE
STAFF MEMBER’S SIGNATURE DATE
FIELD MANAGER’S SIGNATURE DATE
OBSERVATIONAL SURVEYS Page 1 of 6
DSHS 10-528 (REV. 10/2014)